Immunization Divide: Who Do Get Vaccinated in Bangladesh?

Article excerpt

INTRODUCTION

Inequality in health refers to differences in health (outcome or other measures) among different groups in the population. Not all inequalities are, however, unacceptable. Inequality that is deemed 'unfair', 'unacceptable', or 'avoidable' is called inequity (1). In other words, inequity is a subset of inequality. In recent years, there has been an increased discourse in the scientific literature on health equity and inequity (1,2). Most of these analyzed, for very practical reasons, the health outcome (mostly mortality) as a marker of inequities between and within nations. Healthcare-seeking behaviour or access to healthcare has received less attention. It is argued that a mere increase in access itself may not be enough for improving health outcomes since the status of the individual in terms of host factors and background characteristics is an important determinant. Nevertheless, access to healthcare is a key element for sustained improvement in health outcomes. Whereas controversy may arise about the level at which a difference in outcome is considered 'fair' or 'unavoidable', there may not be any such controversy in access as any difference in access within a geo-political entity is avoidable, and is within the reach of human capacities. This paper is an attempt to review inequalities in access to healthcare, focusing on vaccination services in Bangladesh as a case.

Immunization in Bangladesh

Vaccination against some of the most fatal and debilitating diseases is one of the most cost-effective interventions of modern times. Smallpox, which historically caused so much death and suffering, is now a thing of the past. Poliomyelitis, another disabling disease, is now set to be eradicated. The single intervention that has made these to happen is vaccination. Recent studies have also documented the positive health-equity effects of vaccinations. Analyzing longitudinal data on mortality and measles immunization from Bangladesh, Koenig et al. demonstrated that it was the most vulnerable children (in terms of socioeconomic status) whose differential mortality risk was mostly reduced by vaccination (3).

Bangladesh has a long history of vaccinating its population. British colonial papers suggest that variolation or inoculation, the predecessors of vaccination, was in practice in this part of the Indian Sub-continent as far back as 1731; Tikadars, a group of professional inoculators, provided inoculation against smallpox for a fee (4). The modern Expanded Programme on Immunization (EPI) was launched in 1979 but intensified in 1986. With government commitment, donor support, and involvement of non-governmental organizations (NGOs) and civil society, the programme attained spectacular success quickly. Within a few years, the coverage in terms of children fully immunized increased from 2% in 1986 to 62%. In Rajshahi, one of the six administrative divisions of the country, the coverage reached 80% (5,6). This feat, however, was not unique for Bangladesh as similarly rapid improvements were experienced in several other countries in the developing world. The story that unfurled itself afterwards was disquieting, however. Except for 1994 when it reached its peak, the rate has plateaued at around 50% (Fig. 1).

Bangladesh was never able to achieve the target of Universal Child Immunization of 80%, and the plateauing of the coverage rate is even more frustrating. Researchers have looked at the reasons for such plateauing in coverage and have identified factors, which are related to both demand and supply (6,8,9).

In a recent field-level review of routine EPI in northern Bangladesh, participants representing the government and development partners identified the challenges facing the programme. Routine EPI is distinguished from the others interventions, such as National Immunization Days; whereas the former is a regular monthly activity that provides vaccination against the six diseases, the latter is a campaign done twice a year for eradicating a specific disease, such as polio. …